Homeostasis Homeostasis: processes that occur quickly in response to stress – adjustments made rapidly to maintain internal environment. Adaptation: processes resulting in structural or functional changes over time. This is a desired goal. Coping: a compensatory mechanism so that a person can reach equilibrium.
Stress A state produced by change in the environment that is threatening or damaging
Nursing Care Intervene when individual’s own compensatory processes are still functioning. Relate S&S of distress to physiological happenings. Identify person’s position on a continuum of function from wellness/compensation to pathophysiology/disease.
Stress at the Cellular Level Individual cells may cease to function without posing threat to the organism; however as the number of dead cells increases, the specialized function of the tissue is altered – health is threatened.
Nursing Care Assess S&S for indicators of physiologic processes. Relate symptoms/complaints to physical signs. Assist individual to respond to stress with stress management.
Preventing and Correcting FVD Who’s at risk? Replacement Oral Enteral Parenteral
Fluid Volume Excess (FVE) Hypervolemia Weight gain Edema Abnormal lung sounds Increased urine output Puffy eyelids Distended neck veins Tachycardia Increased BP and pulse pressure.
Nursing Care Monitor I & O Daily weight Assess lung sounds Check edema: degree of pitting measure extremities.
Preventing and Correcting FVE Promote rest: favours diuresis and increases circulation (lower) Na+ and fluid intake restrictions Monitor parenteral fluids Positioning
Edema Localized or generalized Occurs when there is a change in capillary member ANASARCA: severe generalized edema ASCITES: edema in peritoneal cavity Dependent area: ankles, feet, sacrum, scrotum, periorbital regions Pulmonary edema: increased fluid in pulmonary interstitium and alveoli
Electrolytes Sodium Normal mmol/L Potassium Normal 3.5-5mmol/L Calcium Normal mmol/L
Sodium: Hyponatremia At Risk Loss of Na Dilution of Na Clinical Manifestations: Anorexia, muscle cramps, exhaustion. Poor skin turgor, dry mucosa/skin Confusion, headache Nursing Care: Monitor I&O Daily weight Encouraging foods high in Na (normal requirement 500mg) Fluid restriction:800ml/day
Sodium: Hypernatremia At Risk Loss of water Gain of sodium Clinical Manifestations Thirst, dry mouth Restlessness, disorientation Edema Increased BP Nursing Care I&O No added salt diet Monitor meds high in Na If IV hypotonic solution used -- want gradual decrease in serum Na 9prevent cerebral edema
Potassium: Hypokalemia At Risk Vomiting/gastric suctioning Alcoholics/cirrhosis Anorexia nervosa Non-K sparing diuretics Clinical Manifestations Muscle weakness, fatigue, anorexia, N&V, leg cramps, dysrrythmia Nursing Care ECG for flattened T-wave ID cause Diet – high K Teaching – use of diuretics, laxatives IV K replacement
Potassium: Hyperkalemia At Risk Kidney disease Addison’s disease Extreme tissue trauma K replacement Clinical Manifestation Ventricular dysrrhythmia, muscle weakness, peaked t-wavwes, respiratory paralysis Nursing Care Verify high serum levels Restrict K foods Teaching re K supplements
Calcium:Hypocalcemia At Risk Renal failure Postmenopausal Low Vit D consumption Antacids, caffeine Hypoparathyroidism Clinical manifestations Tetany, seizures, depression,impaired memory, confusion Nursing Care Seizure precautions Airway status Nutritional intake and supplements Limit alcohol and caffeine
Calcium: Hypercalcemia At Risk Hyperparathyriodism Bone/mineral loss during inactivity Thiazide diuretics Clinical Manifestations Reduced neuromuscular activity, weakness, incoordination, anorexia, constipation Nursing care Increase activity Encourage fluids Encourage fluids Na – favour Ca excretion Safety/comfort
Respiratory Acidosis Individuals at risk Inadequate excretion of carbon dioxide Chronic emphysema, bronchitis Obstructive sleep apnea Obesity Clinical Manifestations Increased cerebrovascular flow (vasodilation) Increased pulse, respirations and BP Mental cloudiness, feelings of fullness in head
Respiratory Alkalosis Nursing Care Recycle carbon dioxide Treat underlying cause
Shock Physiological state in which there is inadequate blood flow to tissues and cells of body Cells try to produce energy anaerobically Leads to low energy yield and acidotic intracellular environment
Categories of Shock Hypovolemic Cardiogenic Circulatory/Distributory
Stages of Shock Compensatory Progressive Irreversible
Compensatory Stage BP normal Vasoconstriction Fight or flight Increased HR Increased contractility Blood shunted to heart and brain.
Nursing Care in Compensatory Stage Close assessment and catch subtle changes before decrease in BP occurs Monitor tissue perfusion. Report deviations in hemodynamic status Reduce anxiety Promote safety
Progressive Stage: Mechanism for regulating BP no longer compensates Respiratory: shallow, rapid Cardiac: dysrrhythmia, ischemia, tachycardia Neurologic: decrease status Renal:failure Hepatic:decrease met. of meds and waste Hematologic:DIC Gastrointestinal: Ischemia, increase risk infection
Nursing Care in Progressive Stage Usually care for in ICU (increased monitoring) Preventing complications Promote comfort and rest Support family members
Irreversible Stage Individual in not responding to treatment. Renal and hepatic failure lead to release of necrotic tissue toxins
Nursing Care in Irreversible Stage Similar to progressive stage Brief explanations to patient Supportive presence for patient and significant others. In collaboration with significant stakeholders, discuss end of life wishes/decisions.
Risks of Fluid Replacement Cardiovascular overload Pulmonary edema
Fluid Replacement: Nursing Care Monitor I& O Mental status Skin perfusion Vital signs Lung sound
Overall Management of Shock Vasoactive medication to improve hemodynamic stability. Myocardial contract Myocradial resistence vasoconstriction Nutritional support Meet needs of increased met. Often parenteral feeding
Hypovolemic Shock Decreased intravascular volume due to fluid loss
Nursing Care in Hypovolemic Shock Prevention Fluid and blood administration Monitor for cardiac overload and pulmonary edema Monitor vital signs I&O Temperature Lung sounds Cardiac rhythm and rate.
Cardiogenic Shock Heart’s ability to contract and pump is impaired General management Correct cause Administer oxygen Control chest pain Monitor hemodynamic status
Nursing Care in Cardiogenic Shock Prevention Monitor hemodynamic status Administer IV fluids and medications Promote safety and comfort
Distributive Shock Blood is abnormally placed in the vasculature Septic - wide spread infection. Number one cause of death in ICU Neurogenic Anaphylactic
Nursing Care in Septic Shock Hyperdynamic phase Hypodynamic phase ID site and source of infection Antipyretic if T >40 Monitor response to medications Comfort measures Oxygen needs
Nursing Care in Neurogenic Shock Results from loss of sympathetic tone Spinal cord injury Spinal anesthesia Nervous system damage Preventative: elevate head 30 degrees Support CV and neuro functions Elastic stockings Elevate head of bed Check Homan’s sign Passive ROM
Nursing Care in Anaphylactic Shock Systemic antigen- antibody reaction Prevention: assess for allergies and observe response to new medications/ blood administration Remove causative agent Support cardiac and pulmonary systems